Factors associated with intensification of oral diabetes medications in primary care provider-patient dyads: a cohort study.
OBJECTIVE
Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults.


METHODS
We conducted a nonconcurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia (A1C > or =8%) enrolled in an academically affiliated managed-care program. Over a 24-month interval (1999-2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit.


RESULTS
Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified for patients with visits that were "routine" (odds ratio [OR] 2.55 [95% CI 1.49-4.38]), for patients taking two or more oral diabetes drugs (2.82 [1.74-4.56]), or for patients with longer intervals between visits (OR per 30 days 1.05 [1.00-1.10]). In contrast, patients with less recent A1C measurements (OR >30 days before the visit 0.53 [0.34-0.85]), patients with a higher number of prior visits (OR per prior visit 0.94 [0.88-1.00]), and African American patients (0.59 [0.35-1.00]) were less likely to have treatment intensified.


CONCLUSIONS
Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.
Bolen
Shari Danielle
SD
Division of General Internal Medicine, Department of Medicine, Johns Hopkins University Schoolof Medicine, Baltimore, Maryland, USA. sgolden4@jhmi.edu
Bricker
Eric
E
Samuels
T Alafia
TA
Yeh
Hsin-Chieh
HC
Marinopoulos
Spyridon S
SS
McGuire
Maura
M
Abuid
Marcela
M
Brancati
Frederick L
FL
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000375:Aging / Q000502:physiology / Q000523:psychology; D015331:Cohort Studies; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy*; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008329:Managed Care Programs; D008396:Maryland; D008875:Middle Aged; D010349:Patient Compliance; D011320:Primary Health Care; D044469:Racial Groups; D018401:Sample Size
D007004:Hypoglycemic Agents